A JAMA THEME ISSUE
Edited by Jeanette M. Smith, MD
A 3-drug regimen is standard care in initial treatment of HIV-infected patients. The possibility that a 4-drug regimen could have superior antiretroviral activity was investigated by Gulick and colleagues, who compared the safety and efficacy of zidovudine and lamivudine plus efavirenz vs zidovudine, lamivudine, and abacavir plus efavirenz in a randomized trial of treatment-naive patients. The authors found no significant benefit from the addition of abacavir in relation to time to virologic failure or CD4 cell counts, nor did they find an increase in adverse events compared with the 3-drug regimen.
Efforts to expand HIV treatment and testing in Africa are the subject of 2 articles in this issue. First, Stringer and colleaguesArticle report favorable patient outcomes following a rapid expansion in availability of antiretroviral therapy at primary care sites in Lusaka, Zambia. In a commentary, Marum and colleaguesArticle describe lessons learned during a scale-up of voluntary HIV counseling and testing programs in Kenya.
In a study conducted in Botswana, newborn infants born to HIV-positive mothers who received antenatal zidovudine were randomly assigned to 6 months of breastfeeding plus prophylactic infant zidovudine or formula feeding plus 1 month of infant zidovudine. During 18 months of follow-up, Thior and colleagues found that breastfeeding with zidovudine was not as effective as formula feeding in preventing postnatal mother-to-child HIV transmission, but breastfeeding was associated with lower cumulative mortality at 7 months. At 18 months, there was no difference in HIV-free survival related to infant feeding strategy.
Simplified HIV treatment regimens are appealing because of fewer adverse effects, lower expense, and improved adherence, but virologic failure during the maintenance phase is not uncommon. Swindells and colleagues investigated the efficacy of maintenance therapy with atazanavir and ritonavir alone in 34 patients who had achieved virologic suppression while taking their first protease inhibitor-based regimen and who discontinued nucleoside analog reverse transcriptase inhibitors (NRTIs) 6 weeks after study enrollment. Twenty-four weeks after discontinuing NRTIs, the authors found that 31 of 34 patients had continued virologic suppression. Among the 3 patients who had virologic failure, plasma atazanavir concentrations were low in 2 and no protease inhibitor resistance mutations were identified.
The human immunodeficiency virus uses the CC chemokine receptor 5 (CCR5) to gain entry into human cells. Lederman and colleagues review the genetics and function of CCR5, effects of CCR5 deletion, and treatment strategies targeting the receptor.
Updated guidelines from the International AIDS Society–USA panel for treatment of adult HIV infection include recommendations for starting antiretroviral therapy, the regimen to use, monitoring of patient response, and circumstances that should prompt changes in therapy.
“Despite the humiliation of his increasing loss of self-control, Ron was still able to defend himself verbally when a stranger cruelly imitated his unsteady gait: ‘I’m not drunk, you idiot, I’m sick. I have AIDS.’” From “Knowing Ron.”
With stepped-up microbicide research in recent years, experts say there is reason for optimism that a safe, effective topical anti-HIV microbicide will be developed and licensed in the not-too-distant future.
Morse and Kovacs review the clinical characteristics and management of metabolic and skeletal complications seen in HIV infection.
New approaches and new resources are needed to control HIV/AIDS in Africa.
Promise and pitfalls of preexposure prophylaxis strategies to reduce incident HIV infections.
For your patients: Information about HIV infection.
This Week in JAMA . JAMA. 2006;296(7):733. doi:10.1001/jama.296.7.733